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NPI Code Detail

MEDICARE: ST JUDE MEDICAL CLINIC SC

MEDICARE: ST JUDE MEDICAL CLINIC SC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician

General Provider Information

NPI Number : 1326186941
Entity Type Code : Organization
Provider Name (Legal Business Name) : ST JUDE MEDICAL CLINIC SC
Provider Business Mailing Address
First Line : 3943 W 31ST ST
Second Line :
City : CHICAGO
State : IL
Zip : 60623-4936
Country : US
Telephone Number : 773-523-8773
Fax Number : 773-523-9259
Provider Business Practice Location Address
First Line : 3943 W 31ST ST
Second Line :
City : CHICAGO
State : IL
Zip : 60623-4936
Country : US
Telephone Number : 773-523-8773
Fax Number : 773-523-9259
Authorized Official
Title or Position : MANAGER
Name : MRS. ROMA SHUKLA
Credential : DO
Telephone Number : 773-523-8773
Provider Enumeration Date : 02/03/2007
Last Update Date : 01/27/2020

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Directions to “ST JUDE MEDICAL CLINIC SC ” Practice Location

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